New Pharmacology

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New Pharmacology

• January 2005

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Objective

• To provide NH prehospital providers with an
  overview of the new medications found in the 2005
  NH Patient Care Protocols.

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• It must be stressed that the following is an
  abbreviated presentation and it is the NH
  providers responsibility to become familiar with
  each medication applicable to his/her provider
  level, including but not limited to

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• Drug name
• Trade name
• Class
• Mechanism of action
• Indications
• Effects

• Contraindication
• Side effects
• Interactions
• Dosages
• Protocol reference
• How Supplied

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How supplied

• Because medication can be purchased from
  various pharmaceutical companies with an
  assortment of packaging variations, it is the
  providers responsibility to be familiar with the
  particulars of each medication in their
  possession.

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Mark - 1 Kit

• Protocols 2.12 2.12P Poisoning/substance
  abuse/overdose 8.3, 8.3P 8.4
  Nerve Agents Organophosphate
• Level Basic, EMT-I, EMT-P

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Mark - 1 Kit

• Mark - 1 Kit contains two autoinjectors.
• Tube 1 Atropine (Atropen)
• Tube 2 Pralidoxime (2-PAM chloride)

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Atropine (Tube 1)

• Trade name Atropen (Tube1)
• Class Parasympatholytic/anticholinergic
• Mechanism of action Muscarinic antagonist
• Indications Organophosphate and nerve agent
  poisonings

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Atropine (Tube 1)

• Contraindications Hypersensitivity, none in
  life threatening mass casualty incident.
• Side effects Blurred vision, dilated pupils, dry
  mouth, tachycardia and drowsiness

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Atropine (Tube 1)

• Dosage Remember this is Tube 1 in a two-drug
  process.
• Adult one autoinjector ( Green label/2.0 mg)
• Infant (0.25mg) Child (15-40 lbs) one autoinjector
  (Blue label / 0.5 mg) Child (40-90 lbs) one
  autoinjector (Red label / 1.0 mg)
• How supplied Autoinjector

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Atropine (Tube 1)

• Paramedics Only
• If Mark-1 Kits are unavailable or IV access has
  been obtained administer
• Adult Atropine 2 mg IV, Repeat every 5 minutes
  until secretions cleared.
• Pediatric Atropine 0.05 - 0.1 mg per kg IV/IO
  or IM (minimum dose of 0.1 mg, maximum dose 5
  mg), repeat 2-5 min as needed.

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Pralidoxime (Tube 2)(pra-li-DOX-eem)

• Trade name 2-PAM, Protopam Chloride
• Class cholinesterase reactivator
• Mechanism of action reactivates cholinesterase
  which has been inactivated by the organophosphate
  or related agents

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Pralidoxime (Tube 2)

• Indications Organophosphate and nerve agent
  poisonings (8.3, 8.3P, 8.4)
• Contraindications Hypersensitivity
• Side effectsBlurred vision, dizziness, diplopia,
  headache, tachycardia, mild weakness and nausea

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Pralidoxime (Tube 2)

• Interactions Caution with barbituates
• Dosage Remember 2PAM is Tube 2 in a two-drug
  process.
• Adult 2-PAM autoinjector
• How supplied autoinjector

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Pralidoxime (Tube 2)

• Paramedics Only
• If Mark-1 Kits are unavailable or IV access has
  been obtained
• Adult Pralidoxime 1-2 gram IV over 3060 min
• Maintenance infusion Up to 500 mg per hour (max.
  of 12 gm/day)

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Pralidoxime (Tube 2)

• Paramedics Only
• If Mark-1 Kits are unavailable or IV access has
  been obtained
• Pediatric Pralidoxime 25 - 50 mg/kg/doses IV/IO
  (maximum dose 1 g) or IM (maximum dose of 2 g),
  may repeat within 30-60 min as needed, then again
  every hour for 1 2 doses as needed.

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For your review
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Ipratropium bromide(i-pra-TROE-pee-um)

• Protocol 2.2 Asthma/COPD/RAD - Adult
• 2.2P Asthma/RAD - Pediatric
• Level Paramedic

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Ipratropium bromide

• Trade name Atrovent
• Class Parasympatholytic bronchodilator
• Mechanism of action Anticholinergic agent,
  chemically related to atropine

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Ipratropium bromide

• Indications Bronchospasm (asthma, chronic
  bronchitis, emphysema, reactive airway disease)
• Contraindications Hypersensitivity to atropine
• Side Effects Blurred vision, drying of bronchial
  secretions, head ache

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Ipratropium bromide

• Dosage
• Adult Aerosol 0.5mg with albuterol 2.5mg, mixed
  in 3ml NS, via nebulizer x 1.
• Pediatric Aerosol 0.25mg (1.25ml of 0.02
  solution) with albuterol 2.5mg (0.5ml of 0.5
  solution), mixed in 3ml NS, via nebulizer x 1
• How supplied 0.5mg/3ml prefilled bullets,
  multi-dose 0.02 solution vials.

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Levalbuterol(lev-al-BYOO-ter-ol)

• Protocol 2.2 Asthma/COPD/RAD - Adult
• 2.2P Asthma/RAD - Pediatric
• Level Paramedic

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Levalbuterol

• Trade name Xopenex, Xopenex Pediatric
• Class Beta 2 agonist
• Mechanism of action Stimulate adenyl cyclase
  from ATP, causing relaxation of the smooth
  muscles of the bronchial tree.

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Levalbuterol

• Indications Bronchospasm (asthma, chronic
  bronchitis, emphysema, reactive airway disease)
• Contraindications Hypersensitivity to albuterol
• Side Effects Tachycardia, headaches, nausea,
  dizziness, anxiety.

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Levalbuterol

• Interactions Antidepressant drugs classified as
  MAO inhibitors or tricyclics , Beta blockers,
  Digoxin or Diuretics
• Dosage
• Adult 1.25 mg via nebulizer.
• Pediactric 0.63 mg via nebulizer.
• How supplied 0.63 mg/3ml vials,

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Metoclopramide(met oh kloe pra' mide)

• Protocol 2.14 Nausea/vomiting
• LevelParamedic

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Metoclopramide

• Trade name Clopra, Emex, Maxeran, Maxolon,
  Octamide, Pramin, Reglan
• Class Antiemetic
• Mechanism of action Dopamine receptor
  antagonist, exact mechanism not clear, but
  appears to sensitize GI smooth muscle to effects
  of acetylcholine by direct action.

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Metoclopramide

• Indications Severe nausea and vomiting
• Contraindications Hypersensitivity, allergy to
  sulfite agents, Hx of seizure, extrapyramidal
  symptoms, pheochromocytoma, GI Obstruction or
  perforation, Hx of breast CA. Use caution with
  CHF, Hypokalemia renal dysfunction, GI
  hemorrhage,

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Metoclopramide

• Side effects Restlessness, drowsiness, fatigue
• Interactions Alcohol and other CNS depressants,
  anticholinergics and opiates analgesics,
  Phonothiazines, MAO inhibitors
• Dosage Metoclopramide 0.1mg/kg IV / IM to max
  of 5 mg.
• How supplied 5 mg/ml

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Norepinephrine

• Protocol 3.7 3.7P Cardiac Arrest
• LevelParamedic

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Norepinephrine

• Trade name Levophed
• Class sympathomimetic
• Mechanism of action alpha agonist,
  vasoconstriction cardiac stimulation
• Indications Cardiac arrest post resuscitation
  with hypotension

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Norepinephrine

• Contraindications Hypersensitivity, normotensive
  or hypertension
• Side effects Anxiety, trembling, headache,
  dizziness, nausea vomiting
• Adult Dose 1 - 30 mcg/min infusion
• Pediatric Dose0.1 mcg/kg/min titrated to desired
  effect. Max 1- 2 mcg/kg/min.
• How supplied dilution to make 4mcg/ml (1mg in
  250ml D5W)

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Phenylephrine (fen-ill-EF-rin)

• Protocol 3.7 Cardiac Arrest
• Dose 100 - 180 mcg loading dose followed by
  infusion 40 - 60 mcg/min. for postresuscitation
  hypotension
• Level Paramedic

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Phenylephrine

• Trade name Neo-Synephrine
• Class Sympathomimetic
• Mechanism of action Stimulates alpha-adrenergic
  receptors, producing pronounced vasoconstriction.

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Phenylephrine

• Indications For post-resuscitation hypotension
  with normal heart rate
• Contraindications Hypersensitivity, severe
  hypertension, V-Tach

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Phenylephrine

• Side effects bradycardia, headache,
  restlessness, rebound miosis, burred vision
• Dosage Phenylephrine 100 - 180 mcg loading dose
  followed by infusion 40 60 mcg/min.
• How supplied 10 mg/ml, (check with your
  pharmacy.)

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Vecuronium (vh-kyour-OH-nee-um)

• Protocol 5.3 RSI
• LevelParamedic

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Vecuronium

• Trade name Norcuron
• Class Nondepolarizing neuromuscular blocking
  agent
• Mechanism of action Competes for cholinergic
  receptors at the motor end-plates

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Vecuronium

• Indications considered with on-line medical
  consultation for continued paralysis
• Contraindications Hypersensitivity,
• Caution with Hepatic disease, impaired
  acid-base, severe obesity, adrenal or
  neuromuscular disease, malignant hyperthermia

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Vecuronium

• Side effectsSkeletal muscle weakness,
  respiratory depression, Malignant hyperthermia
• InteractionsGeneral anesthetic increase
  neuromuscular blockade and duration of action.
  Diuretics, Lithium, Narcotic, Succinylcholine,
  Phenytoin.

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Vecuronium

• Dosage 0.1 mg/kg IVP
• How supplied 10 mg 20 mg vials of microscopic
  crystalline particles.

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Rocuronium

• Protocol 5.3 RSI
• LevelParamedic

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Rocuronium

• Trade name Zemuron
• Class Nondepolarizing neuromuscular blocking
  agent
• Mechanism of actionCompetes for cholinergic
  receptors at the motor end-plates

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Rocuronium

• Indications Considered with on-line medical
  consultation for continued paralysis
• Contraindications Hypersensitivity,
• Caution with hepatic disease, impaired
  acid-base, severe obesity, adrenal or
  neuromuscular disease, malignant hyperthermia

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Rocuronium

• Side effects arrhythmias, tachycardia, vomiting,
  hiccups,
• InteractionsThere are no controlled studies
  documenting the use of rocuronium before or after
  other nondepolarizing muscle relaxants.
  Interactions have been observed when other
  nondepolarizing muscle relaxants have been
  administered in succession.

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Rocuronium

• Dosage1 mg/kg IVP may considered with on-line
  medical consultation for continued paralysis.
  Consider wrist restraints.
• How supplied 10mg/ml

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Ondansetron

• Protocol
• 2.
• Level
• Paramedic

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Ondansetron

• Trade name Zofran
• Class selective antagonist of the serotonin
  receptor subtype, 5-HT3.
• Mechanism of action is not known, probably due
  to the selective antagonish of 50HT3 receptors on
  neurons located in either the peripheral or
  central nervous systems or both

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Ondansetron

• Indications Nausea/vomiting associated with
  chemotherapy radiotherapy
• Contraindications Hypersensitive
• Caution withis not effective in preventing
  motion-induced nausea and vomiting

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Ondansetron

• Side effects headache, constipation, dizziness,
  musculoskeletal pain, drowsiness, fatigue,
  urinary retention, chest pain (rarely)
• Dosage 4 mg IV
• How supplied 2 mg/ml vials